Professional Staff Responsibilities
Facility Director Responsibilities
- Ensures a process that determines only licensed health care professionals, with prescriptive authority in the state where the patient would be tested, can request HSAT.
- May conduct educational sessions on sleep medicine topics to sleep technicians to ensure CEC’s are earned.
- Ensures all staff are trained regarding HIPAA regulations and that patients are informed of their HIPAA rights.
- Oversight of staff training on home sleep apnea testing (HSAT).
Qualifications of Facility Director
- Must be sleep specialist who meets one of the following criteria:
- A Physician or PhD;
- Boarded in sleep by ABSM, AOA, ABMS;
- Physician who completed a 12 month ACGME accredited or AOA accredited fellowship in sleep medicine, and is eligible to sit for and is awaiting first opportunity to apply to sit for the next available sleep board examination;
- Examination must be passed within two examination cycles
Medical Staff Member
Facilities whose facility director is not a licensed physician must have, at minimum, one physician (MD or DO) with a valid, unrestricted license in state where facility is located. Sleep Medical Staff members include, physicians, license psychologists, APRN, and PAs who hold valid licenses in states where patients are evaluated, diagnosed and treated.
Medical Staff Member Responsibilities may Include:
- May review information provided for each direct referral patient & determine if meets criteria for requested test.
- Consultation and Follow up treatment and management.
- May diagnose a medical condition if a licensed physician or APRN (in certain states).
- Only a board certified sleep medicine individual as defined by standard B-2 can review the diagnoses of individuals not boarded in sleep.
- Respond to medical emergencies as appropriate.
- Role as reference sleep specialist, if board certified as defined by standard B-2.
- Treatment recommendations and follow up assessment.
Applicable Accreditation Standards
- All professional staff are to maintain valid, unrestricted licenses commensurate with services they perform in state(s) where patients are seen.
Facilities must designate one single facility director who is board certified in sleep as defined in standard B-2. This individual must be an unrestricted licensed physician or a PhD.
- Qualifications of medical and technical personnel.
- Supervision and oversight of professional and technical staff.
- Direct oversight over testing protocols.
- Recommendation to be on site minimum of 8 hrs. /month.
- Requirement can be met by physical presence or conference calls or virtual meetings.
- Review, report and manage QA program.
Must be determined between each scorer and either facility director or medical staff member who is boarded in sleep as defined by standard B-2, or corporate appointed physician or PhD boarded in sleep.
- Facility director must attest to effectiveness of QA efforts and address remediation if thresholds not met.
- Must sign and date quarterly reports.
Key Things to Keep In Mind
- Facility is to designate only one individual; MD or PhD who is board certified in sleep as the facility director by the ABSM, ABMS or AOA.
- If Facility director is not a licensed physician, there must be one licensed physician on staff that is board certified in sleep medicine.
- On site requirement may be met by physical presence in the facility, teleconferencing, conference calls or virtual meetings and/or webinars with the professional and technical staff members.
- Other professional staff members may be the reference sleep specialist for ISR as long as they are boarded in sleep medicine.
- An individual who is board certified in sleep must review the diagnoses of individuals who are not certified in sleep medicine as defined by standard B-2.